Tag: Medical Insurance Fraud

Medical insurance fraud in hospice is a significant source of whistleblower claims.

Medical insurance fraud in hospice shouldn’t be a surprise. Fraud can occur anywhere, whether it’s a routine doctor’s visit for a healthy person or hospice care for someone who is terminally ill. Some patients will have private insurance to pay for the costs of hospice care. However, most patients seeking hospice care will pay for it through a government program, such as Medicare, Medicaid or Veteran’s Health Administration.

With the extent government money helps pay for hospice care, it’s not surprising that fraud may occur. Have you witnessed fraud and want to report it? Keep the following information in mind so you fully understand what you’re getting into and what you need to do.

What Is Hospice Care?

The exact definition of hospice care will usually depend on the policies and rules set in place by Medicare and Medicaid. However, generally speaking, hospice care includes emotional support and pain management services for those who have a terminal illness and do not expect to live for more than another six months. In the United States, about two-thirds of patients will receive hospice care services in their home.

Just because hospice care refers to someone who is about to pass away, that doesn’t mean government fraud is any less likely. In fact, it might be a little bit easier because of the increased difficulty of detection.

Why Fraud During Hospice Care May Be Difficult to Detect

One reason why illegal billing may be harder to discover for hospice services is due to the sensitivity of the care. Because hospice care concerns an individual who will very likely pass away soon, it may be more uncomfortable for an individual to speak up when something improper takes place.

For example, let’s say you’re a hospice nurse and you know that your patient should receive six pain pills per day. Because your patient receives his hospice care at home, it’s inevitable that a family member will help provide care, including administration of pain medications. You also know that the bottle containing 48 pain pills should last eight days. However, it runs empty after just seven days. So apparently someone either miscounted the number of tablets in the bottle when filling the prescription, the patient is receiving more pain pills than medically necessary or someone is stealing the pain pills.

A Sad Situation Can Get Worse

Over the next few weeks, you decide to pay extra close attention to the bottle of pain medication. You soon discover that it’s a family member that’s stealing some of the pain pills. They are selling them on the street for cash. They’re trying to help pay for other necessary medical expenses not paid for by Medicare or Medicaid. But the day you finally make this discovery, your patient dies. So confronting the family member stealing the pills is probably a bad idea, at least right now. Also, even if you report the family member, they’re stealing the pills to help pay for other medical expenses for their loved one, not for personal profit.

Is healthcare fraud taking place? Probably. Is this something worth reporting? If you do things by the book, then yes, it is. But if the appropriate action takes place, the family member may have to mourn the loss of their loved one from behind bars. This puts you in a difficult position and makes it much easier to not report it and let it slide.

Another reason why it’s extra hard to find fraud in hospice care is because it often takes place at home. This means several things. First, there are fewer medical professionals around the patient. Second, any necessary paperwork is more likely to be accessible by a family member or non-medical professional. Third, given the home setting, it’s easier to ignore or bend any medical rules and procedures. This doesn’t mean impropriety must take place at home during hospice care, but the potential is there.

What This Means When Serving as a Whistleblower

It may be harder to detect Medicare or Medicaid insurance fraud in a hospice setting. Therefore, you’re taking a bigger risk as a whistleblower. Let’s say you’re not calling attention to the fraud for the potential qui tam reward. You only want to do the right thing. You’re still at a higher risk of looking like a bad person who is trying to drag a family or healthcare provider’s name through the mud.

If it’s harder to detect hospice care fraud, then that will also probably mean it will be harder to obtain evidence of the fraud. The result is that if you blow the whistle on someone, you will have greater difficulty proving fraud. This isn’t always going to be the case. But when you’re debating whether or not to report, it will be something to consider.

Want to Speak with an Attorney Experienced with Medical Insurance Fraud in Hospice?

The above information is just something to think about when blowing the whistle. To make the most informed decision possible, you’ll want to speak with an attorney. Look for one who handles medical insurance fraud in hospice care. Contact our skilled medical insurance fraud attorneys at Bothwell Law Group by calling 770.643.1606 today.

Medical insurance fraud commonly comes in the form of kickbacks.

Health services make up a large portion of the American economy, so medical insurance fraud is a common occurrence. Kickbacks are one of the most common forms of illegal behavior in the healthcare setting, but why is this the case? And what are kickbacks, anyway? Read on to find out.

What Are Kickbacks and How Do They Work?

A kickback is similar to a bribe in that one party will pay another party for improper benefits. Looking at an example is the best way to understand what a kickback is.

In a hypothetical healthcare setting, let’s say you have the patient, the patient’s primary care physician, the patient’s insurance company and a doctor who focuses on treating arthritis (we’ll call this doctor “John”). Now let’s assume the patient suffers from joint pain and goes to see his primary care physician. After an examination, the primary care physician believes the patient might have arthritis and refers the patient to Doctor John. The patient sees Doctor John and receives medical treatment. Along the way, the patient’s insurance company pays each doctor for the medical services they provide.

In a hypothetical involving a kickback, the patient’s primary care physician examines the patient. But instead of referring the patient to Doctor John, refers him to Doctor Bob. In return for referring the patient to Doctor Bob, the primary care physician receives a payment from Doctor Bob as a “reward” for sending him a new patient. In this example, the payment Doctor Bob sends to the primary care physician is a kickback.

Why Are Kickbacks Common?

One reason why kickbacks are so easy is that they’re easy to hide. Looking back at the above example, Doctor Bob and the primary care physician could be great friends who spend a lot of time together, perhaps playing golf once a month. During each of these golf games, Doctor Bob puts a roll of unmarked $20 bills in the primary care physician’s golf bag when no one is looking.

Unless the physician tells someone about this kickback, there will be almost no way to identify or trace those unmarked bills. Do you think the primary care physician is going to record the cash in the office business ledger or report it to the IRS as taxable income? The answer is no. An individual can easily hide a few hundred dollars per month of ill-gotten gains by simply using the cash for ordinary purchases. In fact, the primary care physician’s spouse probably won’t even know about it.

But one of the biggest reasons why kickbacks are so common is the nature of the healthcare system in the United States. Before a patient can see a doctor who focuses on a particular area of medicine, they need a referral. In other words, if a patient wants to see Doctor B, they must first see Doctor A. That doctor will give them a referral to see Doctor B.

In a perfect world, Doctor A will always refer patients to the best doctor, whether it’s Doctor B, C or D. Who Doctor A ultimately chooses is a judgment call. Doctors may not be able to provide a plausible reason to explain why they choose to refer a patient to one doctor and not another. This means it’s very easy to set up a situation for kickbacks.

Kickback Coverups

The only difficult part is covering up the kickback itself. As long as the kickback is small, it can probably remain hidden. But healthcare in the United States is expensive. With so much money flowing in and out of hospitals, doctor’s offices and clinics, it’s hard to keep track of it all. On top of that, the medical and financial records created from just one doctor’s visit are immense. Anyone would have trouble sorting through to catch a kickback scheme in action.

This is especially true in cases where a person has numerous medical procedures and bills or is in under medical care for a long period of time. Think of a person who undergoes cancer treatment, then spends several months in hospice before their death. That could be a good example of a case where unscrupulous providers could bill much more than they actually should.

In many situations, only an individual with a very detailed understanding of the financial operations of a healthcare facility can identify a kickback scheme. This is why whistleblowers are so important to stop kickbacks.

Looking for Additional Information about Fraud Related to Medical Insurance?

Of all cases of medical insurance fraud that occur each year, Medicare fraud is the largest source. In 2014, fraudsters scammed Medicare for over $60 billion, and over 2,000 providers have been caught defrauding Medicare. Pursuing Medicare fraud can be difficult due to the prevalence of fraud as well as the sheer number of people involved in defrauding Medicare.

What Is Medical Insurance Fraud?

Medical insurance fraud occurs when a provider or consumer intentionally submits fraudulent information that is used to determine health care benefits payable. Because of the cost of health care and medical equipment, the idea of pocketing the payout of billing for services or equipment that were not rendered is a tempting one for providers and consumers alike. While Medicare is the organization that is most affected by fraud, it can affect any heath insurance company, and can be perpetuated by individual doctors as well as organized groups.

Medicare and related government-provided coverage is the most common target for insurance fraud for a few primary reasons:

Over 54 million people are covered by Medicare, and the organization pays out over $600 billion each year.

The organization is subjected to the loosest monitoring by those in charge.

Billions of dollars are left largely unguarded and ripe for targeting by scam artists.

How Is Medical Insurance Fraud Perpetuated?

There are various ways providers and consumers can commit medical insurance fraud. Some of the most common seen by investigators include the following:

Billing for medical equipment, medication, or services that were not actually rendered, received, or performed.

Upcoding and Unbundling. Upcoding is billing for a service more costly than the one performed. Unbundling is the billing of each step of a procedure as separate procedures.

Accepting kickbacks in exchange for patient referrals.

Waiving co-pays or deductibles and over-billing the insurance company.

Forging or alteration of medical bills or receipts.

Using someone else’s health coverage or insurance card.

Combating Medical Insurance Fraud – a Lengthy Process

Medical insurance fraud is a crime that has serious ramifications for everyone. Every time fraud is committed, it raises the cost of health care for millions of other Americans. So it is important that medical insurance fraud is pursued and prosecuted in order to recoup the amounts that were defrauded.

The challenge in pursuing insurance fraud is finding individuals who are both willing to cooperate with investigators and who have sufficient evidence to back up their claims. Even when a whistleblower contacts authorities with information, it can be a long and arduous process to gather more evidence and bring a court case. But these cases must be pursued in order to help combat the rapidly-rising costs of health care in the United States.

If you have witnessed or participated in medical insurance fraud, you will need protections should you choose to come forward as a whistleblower. Contact the skilled whistleblower attorneys at Bothwell Law Group by calling 770.643.1606 today.